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STATISTICAL MANUAL

FOR THE USE OF

c/L . .: '-■
INSTITUTIONS FOR THE INSANE A s ' *■

PREPARED BY TUB

COMMITTEE ON STATISTICS

OF THE

AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION

IN COLLABORATION WITH THE

BUREAU OF STATISTICS

OF THE

NATIONAL COMMITTEE FOB MENTAL HYGIENE
50 UNION SQUARE, NEW YORK CITY

NEW YORK
1918

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FOREWORD

The American Medico-Psychological Association at its
meeting held in New York, in May 1917, adopted the report
of its Committee on Statistics which provided for a system of
uniform statistics in institutions for mental diseases, and
appointed a standing Committee on Statistics to promote the
introduction of the system throughout the country. This
committee met in New York City on February 7, 1918, and in
cooperation with the National Committee for Mental Hygiene
outlined a plan of procedure.

The National Committee has established a Bureau of Uni-
^ form Statistics and has received a special gift to defray the
i initial expenses of the work of collecting statistics from insti-
tutions for the insane. As close relationships have always
'.^existed between the American Medico-Psychological Associa-
tion and the National Committee, it was thought wise for the
Committee on Statistics to become an advisory committee to
the Bureau of Uniform Statistics of the National Committee
and to have the work of introducing the new system and of
collecting statistics from the institutions carried out by the
Bureau.

In accordance with this arrangement the Bureau, with the
assistance of the Committee on Statistics of the American
Medico-Psychological Association,, has prepared this manual
to assist the institutions in compiling their annual statistics
and has printed a series of forms to be used in preparing
statistical reports. The manual and duplicate forms will be
furnished free to all cooperating institutions, and it is earn-
estly hoped that they will be generally adopted, so that a
national system of statistics of mental diseases may become
an actuality. j! 1 -

Jigmzccty GoOglc

It is recommended that the standardized tables be used in
the annual reports of the institutions so far as possible and
that a duplicate copy of the tables be sent to the Bureau of
Uniform Statistics of the National Committee for Mental
Hygiene as soon as possible after the end of the fiscal year of
the institution.

Albert M. Barrett, Chairman
E. Stanley Abbot
Owen Copp
George H. Kirby
James V. May
Frankwood E. Williams

Committee on Statistics, American
Medico-Psychological Association

Thomas W. Salmon

Medical Director l National Com-
mittee for Mental Hygiene

Eoith M. Fiirbush, Statistician,

Horatio M. Pollock,

' Consulting Statistician,
Bureau of Statistics, National Com-
mittee for Mental Hygiene

Jigitizccty GoOglc

CONTENTS

Page

Foreword . ...,.'. ..... 3

Suggestions for the preparation of statistics 7

Statistical cards .... , ... 8

First admission . 8

Rpadmission . 9

Discharge

Death

Filling in cards

*.'lassifli-atiun of mental diseases

Dtfinitiiina and explanatory notes

Ti HiDiiitti.- p'-yc:i(>4>-4

Senile psychoses

I'-tyrhii^fH with <■> re:.ral arteriimlerusis

General paralysis . . . ,*

Psychoses with cerebral syphilis

Psychoses with Huntington's chores

Psychoses with hrain tumor

Psychoses with other brain or nervous diseases

Alcoholic psychoses

Psychoses due to drug* and other exogenout tosins 20

Psychoses with pellagra 21

Psychoses with other somatic diseases 21

Manic-depressive psychoses . 23

Involution melanrholiB ... . 23

Dementia praecox ... 24

Paranoia or paranoic conditions . . 25

Epileptic psychoses . . 26'

Psyehoneii roses and neuroses . ...... 26

Psychoses with constitutional psychopathic inferiority 27

Psychoses with mental deficiency 28

l.'ndiajmosed psychoses *, 29

Not insane 26

Matistical tallies recommended 30

Directions for the preparation "f statistical tables 31

Table 1 (leneral information 31

Table 2. Financial statement . , . . 38

Table 3. Movement of population 32

Table 4. Nativity 32

Table. 5 Citizenship 33

Table «. Psychoses of first admissions. 34

Table 7. Race 34

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Page

Table 8. Age. of first admissions , 38

Table 9. Degree of education 37

Table 10. Environment 37

Table 11. Eronomic condition 3T

Table 13. Use of alcohol 38

Table 13. Marital condition 38

Table 14. Psychoses of readmissions . . 38-

Table 15. Discharge*! 38

Table lfi. Causes of death . . 3ft

Table 17. Age at time of death 10

Table 18. Duration of hospital life 40

Jigitizocty GoOglc

STATISTICAL MANUAL FOR THE USE OP INSTITU-
TIONS FOR THE INSANE

Statistics of mental disease, to be trustworthy, must be
based on accurate original data. If the facts first ascer-
tained concerning the patients are recorded in a haphazard
way without a clear understanding of the purposes to be
attained, the statistics compiled therefrom will probably be
very defective, if not absolutely worthless.

As a first step in preparing statistics of patients in an
institution for the insane it is necessary to formulate statis-
tical data cards with the essential captions arranged in con-
venient form. Such cards call for the same items of infor-
mation concerning every patient^ and if properly designed
and filled out, will furnish data tbat may be classified in
various ways and tabulated so as to give clear summaries
of important facts concerning the patients and their diseases
and the results of treatment

To facilitate tabulation and filing, it is recommended that
four distinct statistical cards be used, viz. :

1. A first admission card, to be filled out for every insane
patient admitted for the first time to any hospital for the
treatment of mental diseases, except institutions for tempo-
rary care only.

2. A readmission card, to he filled out for every insane
patient admitted who has been previously under treatment in
a hospital for mental diseases, excepting transfers and those
who have received treatment only in institutions for tempo-
rary care.

3. A discharge card, to be filled out for every insane
patient discharged, except transfers.

4. A death card, to be filled out for every insane patient
who dies in the hospital.

It is suggested that first admission cards be printed on
white cardboard, readmission cards on yellow, discharge

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cards on salmon, and death cards on blue, and that in each
instance cards for male patients be printed with black ink
and cards for female patients with red.

Sample forms for the cards are submitted herewith :

FIRST ADMISSION MALE (or female)
State Hospital

Committed
Identification No. Legal status — Voluntary

Psychosis— No. Group Type

Hativity (state or country) of patient of father of motlier Date of

arrival in U. S.
Citizenship of patient — American foreign of father — American foreign

Race Marital condition — Single married widowed divorced separated

Education— None reads only reads and writes common school high school

collegiate
Occupation Religion (Denomination)

Environment— Urban rural Economic condition— Dependent marginal

comfortable
Actual residence— County P. 0.

Time in state
Etiological factors othei than heredity

I Tempera meD tally normal, abnormal (specify)
abnormal (specify!
Family history of mental diseases
Family history of nervous diseases
Family history of mental deficiency
Family history of inebriety (alcohol or drugs) (specify)

f Abstinent
Alcoholic habits of patient J Moderate (specify)

[ Intemperate (specify)
Accompanying physical diseases not an integral part of the j

Duration of present attack before admission yrs. mos.

Number of previous attacks

Date of admission 19 Age on admission yrs.

Presented at staff meeting 19 By Dr.

Hospital number for the year
Note — This card for First Admission to any hospital for the i
[Size of card 5 in. i 8 in.]

Jigitizocty G00g[c

KEADMI88I0N CARD MALE (or female)

State Hospital

Committed
Name Identification No. Legal status — Voluntary

Psychosis — No. Group

Nativity (atate or country) of patie

arrival in U. S.
Citizenship of patient— American foreign of father — American foreign

Race Marital condition — Single married widowed divorced separated

Education— -None reads only reads and writes common school high school

collegiate
Occupation Religion (denomination)

Environment — Urban rural Economic condition — Dependent marginal

comfortable
Actual residence — County P. 0.

Time in state
Etiological factors other than heredity

( Temperamentally normal, abnormal (specify)
abnormal (specify)
Family history of mental diseases
Family history of nervous diseases
Family history of mental deficiency
Family history of inebriety (alcohol or drugs) (specify)

I Abstinent
Alcoholic habits of patient ^ Moderate (specify)

I intemperate (specify)
Accompanying physical diseases not an integral part of the psychosis

Duration of present attack before admission yri. mos. das.

Number of previous attacks

No. of previous admissions Date and duration of each previous hospital

residence (exclusive of parole)
Condition at last discharge Date Hosp

Date of readmiasion 19 Age on readmission yrs.

Presented at staff meeting 19 By Dr.

Hospital number for the year
Note — This card for cases previously admitted to any hospital for the

[Size of card 5 in-, x 8 in.]

Jigitizccty G00g[c

DISCHARGE CARD MALE (or female)

State Hospital

Committed
Hame Identification No. Legal status— Voluntary

Psychosis — No. Group Type

Nativity (state or country) of patient of father of mother

Citizenship of patient — American foreign of father — American foreign

Age on discharge years

Residence when admitted— County P. 0.

No. of previous attacks

No. of previous admissions Date of last admission

Date and duration of each' previous hospital residence (exclusive of parole)

Duration of last psychosis before admisaion years months days

Duration of last hospital residence (exclusive of parole) years months

days
Total duration of hospital life (all admissions, exclusive of paroles) years

months days

Condition on discharge — Recovered much improved improved unimproved
Not insane: Epilepsy alcholism drug addiction constitutional inferiority

mental deficiency dotage others (specify)
Date of parole - 19

Date of discharge 1.9

Patient was discharged to the custody of
Address
Hospital discharge number for the year
[Size of card 5 in. x 8 in.]

DEATH CARD MALE (or female)

State Hospital

Committed
Name Identification No. Legal status — Voluntary

Psychosis — No. Group Type

Nativity (state or country) of patient of father of mother

Citizenship of patient — American foreign of father — American foreign

Age at death years

No. of previous attacks No. of previffua admissions

Date and duration of each previous hospital residence (exclusive of parole)

Duration of last psychosis before admission years months days

Date of last admission

Period of last hospital residence years months days

Total duration of hospital life (all admissions, exclusive of paroles) years

months days

Cause of death (Follow international list of causes and underline principal

Autopsy No yes Findings of autopsy

Residence when admitted— County city or village

Date of death 19

Hospital discharge number for the year

[Size of card 5 in. x 8 in.]

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The facts needed to fill out the admission cards are ob-
tained from (a) the relatives and friends of the patient,
{b) the patient himself, (c) the commitment papers, (d) the
family physician, (e) official documents and records, and
(f) the mental and physical examination of the patient.

The nurse or attendant sent from the hospital to bring in
a patient should be provided with a history blank and should
note thereon all of the important facts concerning the patient
and his family history that can be obtained from relatives
and friends. Additional data should be secured when
friends come to the hospital to visit the patient.

The data required to fill out the discharge and death cards
are obtained from the hospital records. These cards should
always be consistent with the admission cards.

It is advisable to have a statistical data sheet, similar to
the first admission card, filled out and incorporated in the
case record of the patient

At the close of the fiscal year when all the cards are filled
out and checked up, the statistical tables should be made
therefrom. The tabulation can be easily and accurately
done by sorting the cards into groups corresponding to the
table headings and then counting the several groups. The
totals should be made after each count is completed, and mis-
takes rectified before the cards are regrouped.

When the tables for the year are finished, the cards should
be systematically filed according to patients' identification
numbers, all of the cards relating to one patient being brought
together.

Filling in Caeds

Fill in every caption on each card ; if full or accurate in-
formation can not possibly be obtained, enter " U " (symbol
for "facts unascertained").

If the information is negative, enter " none " or " no ".

Do not use the interrogation point {?).

Do not use the dash ( — ) for " unascertained " or for
" negative ".

Do not use the term " several " ; as " several years " ; enter
rather " less than 1 yr.," " between 1 and 5 ym," or " over 10
yrs.," if exact figures can not be obtained.

Avoid round numbers ; accept figures ending with 5 or with
with skepticism and only after close questioning. Avoid,

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e. g., " 1 yr." for 11 nios., 12y 2 mos., etc., and " 1 mo." for 35
days, etc. Avoid " 60 yrs." for 59 or 61 yra

Avoid ambiguous abbreviations; as " lob. pneu." (lobar or
lobular?), "par." (paranoic or paralytic?), etc., and use
only standard abbreviations.

If the place assigned to any caption of the schedule is too
limited to enter all ascertained data, mark the blank "over",
and enter the data on the back of the card.

Entries on all cards should be typewritten. Designate
items on the cards, by underscoring; as, single. Do not cross
out items or use check marks.

CLASSIFICATION OF MENTAL DISEASES
Explanatory notes of the various groups and clinical types
follow the classification.

1. Traumatic psychoses

(a) Traumatic delirium

(b) Traumatic constitution

2. Senile psychoses

(a) Simple deterioration

(b) Presbyophrenic type

(d) Depressed and agitated states in addition to de-

terioration

(e) Paranoid types

(f) Pre-senile types

3. Psychoses with cerebral arteriosclerosis

4. General paralysis

5. Psychoses with cerebral syphilis

6. Psychoses with Huntington's chorea

7. Psychoses with brain tumor

8. Psychoses with other brain or nervous diseases

The following are the more frequent affections and should
be specified in the diagnosis.
Cerebral embolism
Paralysis agitans

Meningitis, tubercular or other forms (to be specified)
Multiple sclerosis
Tabes

Acute chorea
Other conditions (to be specified)

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9. Alcoholic psychoses

(a) Pathological intoxication

(b) Delirium tremens

(d) Acute hallucinosis

(e) Chronic hallucinosis

(f) Acute paranoid type

(g) Chronic paranoid type
(h) Alcoholic deterioration

(i) Other types, acnte or chronic

10. Psychoses due to drugs and other exogenous toxins

(a) Opium (and derivatives), cocaine, bromides,
chloral, etc., alone or combined (to be specified)
("b) Metals, as lead, arsenic, etc. (to be specified)

( c ) Gases ( to be specified )

(d) Other exogenous toxins (to be specified)

11. Psychoses with pellagra

12. Psychoses with other somatic diseases

(a) Delirium with infectious diseases

(b) Post-infectious psychosis

(d) Delirium of unknown origin

(e) Cardio-renal diseases

(f) Diseases of the ductless glands

(g) Other diseases or conditions (to be specified)

13. Manic-depressive psychoses

(a) Manic type

(b) Depressive type

(d) Mixed type

(e) Circular type

14. Involution melancholia

15. Dementia praecox

(a) Paranoid type

(b) Catatonic type

(d) Simple type

16. Paranoia or paranoic conditions

17. Epileptic psychoses

( a) Deterioration

(b) Clouded states

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18. Fsychoneuroses and neuroses

(a) Hysterical type
{ b) Psychasthenic type

(d) Anxiety neuroses

19. Psychoses with constitutional psychopathic inferiority

20. Psychoses with mental deficiency

21. Undiagnosed psychoses

22. Not insane

(a) Epilepsy without psychosis

(b) Alcoholism without psychosis

(d) Constitutional psychopathic inferiority without

psychosis

(e) Mental deficiency without psychosis

(f) Others (to be specified)

DEFINITIONS AND EXPLANATORY NOTES

The following explanatory notes and definitions of the vari-
ous clinical groups were prepared for the Committee by Dr.
George H. Kirby, Director, Psychiatric Institute, Ward's
Island, New York City.
1. Traumatic Psychoses

The diagnosis should be restricted to mental disorders aris-
ing as a direct or obvious consequence of a brain (or head)
injury producing psychotic symptoms of a fairly character-
istic kind. The amount of damage to the brain may vary
from an extensive destruction of tissue to simple concussion
or physical shock with or without fracture of the skull.

Manic-depressive psychoses, general paralysis, dementia
praecox, and other mental disorders in which trauma may
act as a contributory or precipitating cause, should not be
included in this group.

The following are the most common clinical types of trau-
matic psychosis and should be specified in the statistical rec-
ord of the hospital :

(a) Traumatic delirium: This may take the form of an
acute delirium (concussion delirium), or a more protracted
delirium resembling the Korsakow mental complex.

(b) Traumatic constitution : Characterized by a gradual
post-traumatic change in disposition with vasomotor insta-
bility, headaches, fatigability, irritability or explosive emo-

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tionai reactions; usually hyper-sensitiveness to alcohol, and
in some cases development of paranoid, hysteroid, or epilep-
toid symptoms.

(c) Posttraumatic mental enfeeblement (dementia):
Varying degrees of mental reduction with or without aphasic
symptoms, epileptiform attacks or development of a cerebral
arteriosclerosis.
2. Senile Psychoses

A well denned type of psychosis which as a rule develops
gradually and is characterized by the following symptoms :
Impairment of retention (forgetfulness) and general failure
of memory more marked for recent experiences; defects in
orientation and a general reduction of mental capacity; the
attention, concentration and thinking processes are inter-
fered with ; there is self-centering of interests, often irrita-
bility and stubborn opposition; a tendency to reminiscences
and fabrications. Accompanying this deterioration there may
occur parauoid trends, depressions, confused states, etc. Cer-
tain clinical types should therefore be specified, but these
often overlap :

(a) Simple deterioration : Retention and memory defects,
reduction in intellectual capacity and narrowing of interests;
usually also suspiciousness, irritability and restlessness, the
latter particularly at night

(b) Presbyophrenic type: Severe memory and retention
defects with complete disorientation; but at the same time
preservation of mental alertness and attentiveness with
ability to grasp immediate impressions and conversation quite
well. Forgetfulness leads to absurd contradictions and repe-
titions; suggestibility and free fabrication are prominent
symptoms. (The general picture resembles the Korsakow
mental complex. )

(c) Delirious and confused types: Often in the early
stages of the psychosis and for a. long period the picture is
one of deep confusion or of a delirious condition.

id) Depressed and agitated types: In addition to the un-
derlying deterioration there may be a pronounced depression
and persistent agitation.

(e) Paranoid types: Well marked delusional trends,
chiefly persecutory or expansive ideas, often accompany the
deterioration and in the early stages may make the diagnosis
difficult if the defect symptoms are mild.

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(f) Pre-senile types : The so-called "Alzheimer's disease."
An early senile deterioration which usually leads rapidly to
a deep dementia. Reported to occur as early as the fortieth
year. Most cases show an irritable or anxious depressive
mood with aphasic or apractie symptoms.- There is apt to he
general rcsistiveness and sometimes spasticity.

3. Psychoses with Cerebral Arteriosclerosis

The clinical symptoms, both mental and physical, are
varied depending in the first place on the distribution and
severity of the vascular cerebral disease and probably to some
extent on the mental make-up of the person.

Cerebral physical symptoms, headaches, dizziness, fainting
attacks, etc., are nearly always present, and usually signs of
focal brain disease appear sooner or later (aphasia, paralysis,
etc.).

The most important mental symptoms (particularly if the
arteriosclerotic disease is diffuse) are impairment of mental
tension, i. e., interference with the capacity to think quickly
and accurately, to concentrate and to fix the attention; fatig-
ability and lack of emotional control {alternate weeping and
laughing), often a tendency to irritability is marked; the re-
tention is impaired and with it there is more or less general
defect of memory, especially in the advanced stages of the
disease, or after some large destructive lesion occurs.

Pronounced psychotic symptoms may appear in the form
of depression (often of the anxious type), suspicions or para-
noid ideas, or episodes of marked confusion.

To be included in this group are the psychoses following
cerebral softening or hemorrhage, if due to arterial disease.
(Autopsies in state hospitals show that in arteriosclerotic
cases softening is relatively much more frequent than hem-
orrhage. )

Differentiation from senile psychosis is sometimes difficult
particularly if the arteriosclerotic disease manifests itself in
the senile period. The two conditions may be associated;
when this happens preference should he given in the statis-
tical report to the arteriosclerotic disorder.

nigh blood pressure, although usually present, is not essen-
tial for the diagnosis of cerebral arteriosclerosis.

4. General Paralysis

The range of symptoms encountered in general paralysis is
too great to be reviewed here in detail. As to mental symp-

3igitizGabyCj009lC

toms. most stress should be laid on the early changes in dis-
position and character, judgment defects, difficulty about
time relations and discrepancies in statements, forgetfulness
and later on a diffuse memory impairment. Cases with
marked grandiose trends are less likely to be overlooked than
cases with depressions, paranoid ideas, alcoholic-like episodes,
etc.

Mistakes of diagnosis are most apt to be made in those cases
having in the early stages pronounced psychotic symptoms
and relatively slight defect symptoms, or cases with few. defi-
nite physical signs. Lumbar puncture should always be made
. if there is any doubt about the diagnosis. A Wassennann
examination of the blood alone is not sufficient as this does
not tell us whether or not the central nervous system is in-
volved.
5. Psychoses with Cerebral Syphilis

Since general paralysis itself is now known to be a paren-
chymatous form of brain syphilis, the differentiation of the
cerebral syphilis eases might on theoretical grounds be re-
garded as less important than formerly. Practically, how-
ever, the separation of the non-parenchymatous forms is
very important because the symptoms, the course and thera-
peutic outlook in most of these cases are different from those
of general paralysis.

According to the predominant pathological characteristics,
three types of cerebral syphilis may be distinguished, viz. :
(a) Meningitic, (b) Endarteritic, and (r) Gummatous. The
lines of demarcation between these types are not, however,
sharp ones. We practically always find in the endarteritic
and gummatous types a certain amount of meningitis.

The acute meningitic form is the most frequent type of cere-
bral syphilis and gives little trouble in diagnosis; many of
these cases do not reach state hospitals. In most cases after
prodromal symptoms (headache, dizziness, etc.) there is a
rapid development of physical signs, usually cranial nerve
involvement, and a mental picture of dullness or confusion
with few psychotic symptoms except those related to a deliri-
ous or organic reaction.

In the rarer chronic meningitic- forms which are apt to
occur a long time after the syphilitic infection, usually in
the period in which we might expect general paralysis the
diagnostic difficulties may be considerable.

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In the endarteritic forms the most characteristic symptoms
are those resulting from focal vascular lesions.

In the gummatous forms the slowly developing focal and
pressure symptoms are most significant

In all forms of cerebral syphilis the psychotic manifesta-
tions are less prominent than in general paralysis and the
personality is much better preserved as shown by the social
reactions, ethical sense, judgment and general behavior. The
grandiose ideas and absurd trends of the general paralytic
are rarely encountered in these cases.

6. Psychoses With Huntington's Chorea

Mental. symptoms are a constant accompaniment of this
form of chorea and as a rule become more marked as the dis-
ease advances. Although the disease is regarded as being
hereditary in nature, a diagnosis can be made on the clinical
picture in the absence of a family history.

The chief mental symptoms are those of mental inertia
and an emotional change, either apathy and silliness or a de-
pressive irritable reaction with a tendency to passionate out-
bursts. As the disease progresses the memory is affected to
some extent, but the patient's ability to recall past events
is often found to be surprisingly well preserved when the dis-
inclination to cooperate and give information can be over-
come. Likewise the orientation is well retained even when
the patient appears very apathetic and listless. Suspicions
and paranoid ideas are prominent in some cases.

7. Psychoses with Brain Tumor

A large majority of brain tumor cases show definite mental
symptoms. Most frequent are mental dullness, somnolence,
hebetude, slowness in thinking, memory failure, irritability
and depression, although a tendency to facetiousness is some-
times observed. Episodes of confusion with hallucinations
are common; some cases express suspicions and paranoid
ideas.

The diagnosis must rest in most cases on the neurological
symptoms, and these will depend on the location, size and
rate of growth of the tumor. Certain general physical symp-
toms due to an increased intra-cranial pressure are present-
in most cases, viz: headache, dizziness, vomiting, slowing of
the pulse, choked disc and interlacing of the color fields.

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8. Psychoses with other Brain or Nervous Diseases

This division provides a place for grouping a variety of
less common mental disorders associated with organic dis-
ease of the nervous system and not included in the preceding
larger groups. On the card the special type of brain or
nervous diseases should be mentioned after the group name.
The following are the conditions most frequently met with :

(a) Cerebral embolism (if an incident in cerebral arteri-
osclerosis it should be placed in group 3).

(b) Paralysis agitans.

(d) Multiple sclerosis.

(e) Tabes (paresis to be carefully excluded).

(f) Acute chorea (Sydenham's type). Hysterical chorea
to be excluded.

(g) Other conditions (to be specified).

9. Alcoholic Psychoses

The diagnosis of alcoholic psychosis should be restricted to
these mental disorders arising with few exceptions in connec-
tion with chronic drinking and presenting fairly well defined
symptom-pictures. One must guard against making the alco-
holic group too inclusive. Over-indulgence in alcohol is often
found to be merely a symptom of another psychosis, or at
any rate may be incidental to another psychosis, such as gen-
eral paralysis, manic-depressive insanity, dementia praecox,
epilepsy, etc. The cases to be regarded as alcoholic psychoses
which do not result from chronic drinking are the episodic
attacks in some psychopathic personalities, the dipsomanias
(the true periodic drinkers) and pathological intoxication,
any one of which may develop as the result of a single imbibi-
tion or a relatively short spree.

The following alcoholic reactions usually present symptoms
distinctive enough to allow of clinical differentiation:

(a) Pathological intoxication: An unusual or abnormal
immediate reaction to taking a large or small amount of al-
cohol. Essentially an acute mental disturbance of short dur-
ation characterized usually by an excitement or furor with
confusion and hallucinations, followed by amnesia.

(b) Delirium tremens: An hallucinatory delirium with
marked general tremor and toxic symptoms.

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(c) Korsakow's psychosis: This occurs with or without
polyneuritis. The delirious type is not readily differen-
tiated in the early stages from severe delirium tremens hut
is more protracted. The non-delirious type presents a char-
acteristic retention defect wi,tli disorientation, fabrication,
suggestibility and tendency to misidentify persons. Hallu-
cinations are infrequent after the- acute phase.

(d) Acute hallucinosis: This is chiefly an auditory hal-
lucinosis of rapid development with clearness of the sen-
sorium, marked fears, and a more or less systematized per-
secutory trend.

(e) Chronic hallucinosis: This is an infrequent type
which may he regarded as the persistence of the symptoms
of the acute hallucinosis without change in the character of
the symptoms except perhaps a gradual lessening of the emo-
tional reaction accompanying the hallucinations.

(f) Acute paranoid type: Suspicions, misinterpretations,
and persecutory ideas, often a jealous trend; hallucinations
usually subordinate; clearing up on withdrawal of alcohol.

(g) Chronic paranoid type: Persistence of symptoms of
the acute paranoid type with fixed delusions of persecution
or jealousy usually not influenced by withdrawal of alcohol;
difficult to differentiate from non-alcoholic paranoid states
or dementia praecox.

(h) Alcoholic deterioration: A slowly developing moral,
volitional and emotional change in the chronic drinker; ap-
parently relatively few cases are committed as the mental
symptoms are not usually looked upon as sufficient to justify
the diagnosis of a definite psychosis. The chief symptoms are
ill humor and irascibility or a jovial, careless, facetious
mood; ahusiveness to family, unreliability and tendency to
prevarication; in some cases definite suspicions and jeal-
ousy ; there is a general lessening of efficiency and capacity
for physical and mental work; memory not seriously im-
paired. To be excluded are residual defects due to Kor-
sakow's psychosis, or mental reduction due to arteriosclerosis
or to traumatic lesions.

(i) Other types to be specified.
10. Psychoses Due to Drugs and other Exogenous Toxins

The clinical pictures produced by drugs and other exogen-
ous poisons are principally deliria or states of confusion;

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although sometimes hallucinatory and paranoid reactions are
met with. Certain poisons and gases apparently produce
special symptoms, e. g., cocaine, lead, illuminating gas, etc.
Grouped according to the toxic etiological factors the follow-
ing are to be differentiated :

(a) Opium (and derivatives), cocaine, bromides, chloral,
etc., alone or combined ( to be specified )

(b) Metals, as arsenic, lead, etc. (to be specified)

(d) Other exogenous toxins (to be specified)

11. Psychoses with Pellagra

The relation which various mental disturbances bear to the
disease pellagra is not yet settled. Cases of pellagra occur-
ring during the course of a well established mental disease
such as dementia praecox, manic-depressive insanity, senile
dementia, etc.; should not be included in this group. The
mental disturbances which are apparently most intimately
connected with pellagra are certain delirious or confused
states (toxic-organic-like reactions) arising during the course
of a severe pellagra. These are the cases which for the pres-
ent should be placed in the group of psychoses with pellagra

12. Psychoses with other Somatic Diseases

Under this heading are brought together those mental dis-
orders which appear to depend directly upon some physical
disturbance or somatic disease not already provided for in .
the foregoing groups.

In the types designated below under (a) to (e) inclusive,
we have essentially deliria or states of confusion arising dur-
ing the course of an infectious disease or in association with
a condition of exhaustion or a toxaemia. The mental dis-
turbance is apparently the result of interference with brain
nutrition or the unfavorable action of certain deleterious sub-
stances, poisons or toxins, on the central nervous system. The
clinical pictures met with are extremely varied. The delirium
may be marked by severe motor excitement and incoherence
of utterance, or by multiform hallucinations with deep con-
fusion or a dazed, bewildered condition ; epileptiform attacks,
catatonic-like symptoms, stupor, etc. may occur. In classify :
ing these psychoses a difficult problem arises in many cases
if attempts are made to distinguish between infection and ex-

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haustion as etiological factors. For statistical reports the
following differentiations should be made :

Under (a) "Delirium with infectious diseases" place the
initial deliria which develop during the prodromal or incuba-
tion period or before the febrile stage as in some cases of
typhoid, small-pox, malaria, etc. ; the febrile deliria which
seem to bear a definite relation to the rise in temperature;
the post-febrile deliria of the period of defervescence includ-
ing the so-called " collapse delirium."

Under (b) " Post-infectious psychoses " are to be grouped
deliria, the mild forms of mental confusion, or the depressive,
irritable, suspicious reactions which occur during the period
of convalescence from infectious diseases. Physical asthenia
and prostration are undoubtedly important factors in these
conditions and differentiation from " exhaustion deliria "
must depend chiefly on the history and obvious close rela-
tionship to the preceding infectious disease. (Some cases
which fail to recover show a peculiar mental enfeeblement )
In this group should be classed the " cerebropathica psychica
toxaemica" or the non-alcoholic polyneuritic psychoses fol-
lowing an infectious disease as typhoid, influenza, septi-
caemia, etc.

Under (c) "Exhaustion deliria" are to be classed psy-
choses in which physical exhaustion, not associated with or
the result of an infectious disease, is the chief precipitating
cause of the mental disorder, e. g., hemorrhage, severe phy-
sical over-exertion, deprivation of food, prolonged insomnia,
debility from wasting disease, etc.

Of the psychoses which occur with diseases of the ductless
glands, the best known are the thyrogenous mental disor-
ders. Disturbance of the pituitary or of the thymus func-
tion is often associated with mental symptoms.

According to the etiology and symptoms the following
types should therefore be specified under " Psychoses with
Other Somatic Diseases:"

(a) Delirium with infectious disease (specify)

(b) Post-infectious psychosis (specify)

(d) Delirium of unknown origin

(e) Cardio-renal disease

(f) Diseases of the ductless glands (specify)

■- '(g) Other diseases or conditions (to be specified)

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13. Manic-Depressive Psychoses

This group comprises the essentially benign affective psy-
choses, mental disorders which fundamentally are marked by
emotional oscillations and a tendency to recurrence. Vari-
ous psychotic trends, delusions, illusions and hallucinations,
clouded states, stupor, etc. may be added. To be dis-
tinguished are:

The manic reaction with its feeling of well-being (or irasci-
bility), flight of ideas and over-activity.

The depressive reaction with its feeling of mental and phy-
sical insufficiency, a despondent, sad or hopeless mood and
in severe depressions, retardation and inhibition; in some
cases the mood is one of uneasiness and anxiety, accompanied
by restlessness.

The mixed reaction, a combination of manic and depressive
symptoms.

The stupor reaction with its marked reduction in activity,
depression, ideas of. death, and often dream-like hallucina-
tions; sometimes mutism, drooling and muscular symptoms
suggestive of the catatonic manifestations of dementia prae-
cox, from which, however, these manic-depressive stupors are
to be differentiated.

An attack is called circular when, as is often the case, one
phase is followed immediately by another phase, e. g., a manic
reaction passes over into a depressive reaction or vice versa.

Oases formerly classed as allied to manic-depressive should
be placed here rather than in the undiagnosed group.

In the statistical reports the following should be specified :

(ft) Manic attack

(b) Depressive attack

(d) Mixed attack

(e) Circular attack

14. Involution Melancholia

These depressions are probably related to the manic-depres-
sive group; nevertheless the symptoms and the course of the
involution cases are sufficiently characteristic to justify us in
keeping them apart as special forms of emotional reaction.

To be included here are the slowly developing depressions
of middle life and later years which come on with worry, in-
somnia, uneasiness, anxiety and agitation, showing usually
the unreality and sensory complex, but little or no evidence

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of any difficulty in thinking. The tendency is for the course
to be a prolonged one. Arteriosclerotic depressions should
be excluded.

When agitated depressions of the involution period are
clearly superimposed on a manic-depressive foundation with
previous attacks (depression or excitement) they should for
statistical purposes be classed in the manic-depressive group.
15. Dementia Praecox

This group cannot be satisfactorily defined at the present
time as there are still too many points at issue as to what con-
stitute the essential clinical features of dementia praecox. A
large majority of the cases which should go into this group
may, however, be recognized without special difficulty, al-
though there is an important smaller group of doubtful, atypi-
cal allied or transitional cases which from the standpoint of
symptoms or prognosis occupy an uncertain clinical position,

Oases formerly classed as allied to dementia praecox should
be placed here rather than in the undiagnosed group. The
term " schizophrenia" is now used by many writers instead
of dementia praecox.

The following mentioned features are sufficiently well es-
tablished to be considered most characteristic of the dementia
praecox type of reaction :

A seclusive type of personality or one showing other evi-
dences of abnormality in the development of the instincts and
feelings.

Appearance of defects of interest and discrepancies be-
tween thought on the one hand and the behavior-emotional
reactions on the other.

A gradual blunting of the emotions, indifference or silliness
with serious defects of judgment and often hypochondriacal
complaints, suspicions or ideas of reference.

Development of peculiar trends, often fantastic ideas, with
odd, impulsive or negativistic conduct not accounted for by
any acute emotional disturbance or impairment of the sen-
sorium.

Appearance of autistic thinking and dream-like ideas,
peculiar feelings of being forced, of interference with the
mind, of physical or mystical influences, but with retention of
clearness in other fields (orientation, memory, etc.).

According to the prominence of certain symptoms in indi-

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vidua] cases the following four clinical forms of dementia
praeeox may be 'specified, but it should be borne in mind
that these are only relative distinctions and that transitions
from one clinical form to another are common :

(a) Paranoid type; Cases characterized by a prominence
of delusions, particularly ideas of persecution or grandeur,
often connectedly elaborated, and hallucinations in various
fields.

(b) Catatonic type : Cases in which there is a prominence
of negativistic reactions or various peculiarities of conduct
with phases of stupor or excitment, the latter characterized
by impulsive, queer or stereotyped behavior and usually hal-
lucinations.

(e) Hebephrenic type: Cases showing prominently a
tendency to silliness; smiling, laughter, grimacing, manner-
isms in speech and action, and numerous peculiar ideas
usually absurd, grotesque and changeable in form.

(d) Simple type: Cases characterized by defects of in-
terest, gradual development of an apathetic state, often with
peculiar behavior, but without expression of delusions or
hallucinations.

16. Paranoia or Paranoic Conditions

From this group should be excluded the deteriorating para-
noic states and paranoic states symptomatic of other mental
disorders or of some damaging factor such as alcohol, or-
ganic brain disease, etc.

The group comprises cases which show clinically fixed sus-
picions, persecutory delusions, dominant ideas or grandiose
trends logically elaborated and with due regard for reality
after once a false interpretation or premise has been ac-
cepted. Further characteristics are formally correct con-
duct, adequate emotional reactions, clearness and coherence
of the train of thought

17. Epileptic Psychoses

In addition to the epileptic deterioration, transitory psy-
choses may occur which are usually characterized by a
clouded mental state followed by an amnesia for external
occurrences during the attack. (The hallucinatory and
■dream-like experiences of the patient during the attack may
be vividly recalled. ) Various automatic and secondary states
of consciousness may occur.

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According- to the most prominent clinical features the epi-
leptic mental disorders should therefore be specified as fol-
lows :

(a) Deterioration: A gradual development of mental dull-
ness, slowness of association and thinking, impairment of
memory, irritability or apathy.

(b) Clouded states: Usually in the form of dazed reac-
tions with deep confusion, bewilderment and anxiety or ex-
citements with hallucinations, fears and violent outbreaks;
instead of fear there may be ecstatic moods with religious
exaltation.

18. Psychoneuroses and Neuroses

The psychoneurosis group includes those disorders in
which mental forces or ideas of which the subject is either
aware (conscious) or unaware (unconscious) bring about
various mental and physical symptoms; in other words these
disorders are essentially psychogenic in nature.

The term neurosis is now generally used synonymously
with psychoneurosis, although it has been applied to certain
disorders in which, while the symptoms are both mental and
physical, the primary cause is thought to be essentially phy-
sical. In most instances, however, both psychogenic and phy-
sical causes are operative and we can assign only a relative
weight to the one or the other.

The following types are sufficiently well defined clinically
to be specified:

(a) Hysterical type: Episodic mental attacks in the form
of delirium, stupor or dream states during which repressed
wishes, mental conflicts or emotional experiences detached
from ordinary consciousness break through and temporarily
dominate the mind. The attack is followed by partial or
complete amnesia. Various physical disturbances (sensory
and motor) occur in hysteria, and these represent a conver-
sion of the affect of the repressed disturbing complexes into
bodily symptoms or, according to another formulation, there
is a dissociation of consciousness relating to some physical
function.

(b) Psychasthenic type: This includes the compul-
sive and obsessional neuroses of some writers. The main

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clinical characteristics are phobias, obsessions, morbid doubts
and impulsions, feelings of insufficiency, nervous tension and
anxiety. Episodes of marked depression and agitation may
occur. There is no disturbance of consciousness or amnesia
as in hysteria.

(c) Neurasthenic type: This should designate the fatigue
neuroses in which physical as well as mental causes evidently
figure; characterized essentially by mental and motor fatig-
ability and irritability; also various hyperesthesias and
paraesthesias ;' hypochondriasis and varying degrees of de-
pression.

(d) Anxiety neuroses: A clinical type in which morbid
anxiety or fear is the most prominent feature. A general
nervous irritability (or excitability) is regularly associated
with the anxious expectation or dread ; in addition there are
numerous physical symptoms which may be regarded as the
bodily accompaniments of fear, particularly cardiac and
vasomotor disturbances : the heart's action is increased, often
there is irregularity and palpitation: there may be sweating,
nausea, vomiting, diarrhea, suffocative feelings, dizziness,
trembling, shaking, difficulty in locomotion, etc. Fluctua-
tions occur in the intensity of the symptoms, the acute exacer-
bations constituting the " anxiety attack."

19. Psychoses with Constitutional Psychopathic Inferiority
Under the designation of constitutional psychopathic in-
feriority is brought together a large group of pathological
personalities whose abnormality of make-up is expressed
mainly in the character and intensity of their emotional and
volitional reactions. Individuals with an intellectual defect
(feeblemindedness) are not to be included in this group,

Several of the preceding groups, in fact all of the so-called
constitutional psychoses, manic-depressive, dementia prae-
cox, paranoia, psyehoneuroses, etc., may be considered as aris-
ing on a basis of psychopathic inferiority because the previ-
ous mental make-up in these conditions shows more or less
clearly abnormalities in the emotional and volitional spheres,
These reactions are apparently related to special forms of
psychopathic make-up now fairly well differentiated, and the
associated psychoses also have their own distinctive features.
There remain, however, various other less well differen-
tiated types of psychopathic personalities, and in these the

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psychotic reactions (psychoses) also differ from those al-
ready specified in the preceding groups.

It is these less well differentiated types of emotional and
volitional deviation which are to be designated, at least for
statistical purposes, as constitutional psychopathic inferior-
ity. The type of behavior disorder, the social reactions, the
trends of interests, etc., which the psychopathic inferior may
show give special features to many cases, e. g., criminal
traits, moral deficiency, tramp life, sexual perversions and
various temperamental peculiarities.

The pronounced mental disturbances or psychoses which
develop in psychopathic inferiors and bring about their com-
mitment are varied in their clinical form and are usually of
an episodic character. Most frequent are attacks of irrita-
bility, excitement, depression, paranoid episodes, transient
confused states, etc. True prison psychoses belong in this
group.

In accordance with the standpoint developed above, a psy-
chopathic inferior with a manic-depressive attack should be
classed in the manic-depressive group, and likewise a psy-
chopathic inferior with a schizophrenic psychosis should go
in the dementia praecox group.

Psychopathic inferiors without an episodic mental attack
or any psychotic symptoms should be placed in the not insane
group under the appropriate sub-heading.

20. Psychoses with Mental Deficiency

This group includes the psychoses with various types of
intellectual deficiency or feeblemindedness. The degree of
mental deficiency should be determined by the history and
the use of standard psychometric tests. The intellectual
level may be denoted in the statistics by specifying moron,
imbecile, idiot

Acute, usually transient psychoses of various forms occur
in mentally deficient persons and commitment to a hospital
for the insane may be necessary. The most common mental
disturbances are episodes of excitement or irritability, de-
pressions, paranoid trends, hallucinatory attacks, etc.

Mentally deficient persons may suffer from manic-depres-
sive attacks or from dementia praecox. When this occurs
the diagnostic grouping should be manic-depressive or de-
mentia praecox as the case may he.

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Mental deficiency cases without psychotic disturbances
should go into the group of not insane under the appropriate
sub-heading. ■

/ 21. Undiagnosed Psychoses

In this group should be placed the cases in which a satis-
factory diagnosis cannot he made and the psychosis must
therefore be regarded as an unclassified one. The difficulty
may be due to lack of information or inaccessibility of the
patient; or the clinical picture may be obscure, the etiology
unknown, or the symptoms unusual. Cases placed in this
group during the year should be again reviewed before the
annual diagnostic tables are completed.

Cases of the type formerly placed in one of the allied
groups should not be put in the undiagnosed group except
for some special reason. Most of the cases hitherto called
allied should be placed in the main group to winch they seem
most closely related.

/ 22. Not Insane

This group should receive the occasional case which after
investigation and observation gives no evidence of having had
a psychosis. The only difficulty likely to be encountered in the
statistical reports will arise in the grouping of patients who
have recovered from a psychosis prior to admission. In such
cases, if the history, the commitment papers or .the patient's
retrospective account shows that a psychosis actually existed
immediately before admission, that is, at the time of com-
mitment, then the case should be considered as having suf-
fered from a mental disorder, and classification under the ap-
propriate heading should be made.

If it is determined that no psychosis existed, then the con-
dition which led to admission should be specified. The fol-
lowing come most frequently into consideration:

(a) Epilepsy without psychosis

(b) Alcoholism without psychosis

(d) Constitutional psychopathic inferiority without psy-

chosis

(e) Mental deficiency without psychosis

(f) Other conditions (to be specified)

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STATISTICAL TABLES RECOMMENDED
A series of eighteen statistical tables is recommended for
the use of all institutions for the insane. These provide for
the systematic presentation of the data that should be an-
nually compiled by every such institution and that should
be available for use by everyone interested in psychiatry or
the treatment of mental diseases. These tables are:

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

General information.
Financial statement
Movement of patients.
Nativity and parentage of first admissions.
Citizenship of first admissions.
Psychoses of first admissions, types as well as
principal psychoses to be designated.

Table 7. Race of first admissions classified with reference
to principal psychoses.

Table 8. Age of first admissions classified with reference
to principal psychoses.

Table 9. Degree of education of first admissions classified
with reference to principal psychoses.

Table 10. Environment of first admissions classified with
reference to principal psychoses.

Table 11. Economic condition of first admissions classified
with reference to principal psychoses.

Table 12. Use of alcohol by first admissions classified with
reference to principal psychoses.

Table 13. Marital condition of first admissions classified
with reference to principal psychoses.

Table 14. Psychoses of readmissions, types as well as prin-
cipal psychoses to be designated.

Table 15. Discharges of patients classified with reference
to principal psychoses and condition on dis-
cbarge.

Table 16. Causes of death of patients classified with refer-
ence to principal psychoses.

Table 17. Age of patients at time of death classified with
reference to principal psychoses.

Table 18. Duration of hospital life of patients dying in hos-
pital, classified with reference to principal

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The National Committee for Mental Hygiene has printed
a series of forms to be used in preparing the foregoing tables
and will furnish them free to every institution requesting
them or that signifies its willingness to cooperate in the gen-
eral movement for uniform statistics. The forms are num-
bered to correspond with the tables. In order to secure uni-
formity in filling out the blanks the following explanations
and definitions are submitted :

directions fob the preparation of statistical tables
Table 1. General Information

The data relative to hospital plant, medical service, em-
ployees and patients, called for in this table, should be given
as of the last day of the fiscal year of the institution.

Hospital plant: The value of the hospital property
should be estimated at cost unless its original value has been
diminished by depreciation. In case a considerable amount
of depreciation has occurred, a reasonable allowance there-
for should be made. As the estimates of the value of hospital
property in different institutions will be subject to compari-
son, the appraisal in each case should be made with care and
should represent as nearly as possible the true value of the
property.

Medical service: The term " assistant physicians," as
used in the table, includes all physicians regularly employed
in the hospital in a grade below that of superintendent and
above that of medical interne. The term " clinical assist-
ants " includes physicians and medical students who are em-
ployed temporarily or permanently in hospital work below
the grade of medical interne.

Consulting physicians, eye and ear specialists, dentists,
and pharmacists, are not to be included ia the report of the
medical service.

Employees: The term " graduate nurses " includes only
those nurses who have graduated from a school of nursing
maintained by a general hospital or a hospital for the insane
giving a course covering at least two years.

The term " social workers " refers to persons regularly em-
ployed by the hospital to look after the interests of parole
and other out-patients. Voluntary workers in this field are
not to be included in the table.

Jigitizccty GoOglc

Table 2. Financial Statement
The data should be given in accordance with the headings
provided in the table so far as possible. If it is impossible
to supply the data pertaining to any of the items the total
receipts and disbursements should be given and explanations
concerning their classification may be submitted in detail on
a separate sheet. The various terms in the table are used in
the ordinary sense and are self-explanatory.

Table 3. Movement of Insane Patient Population

This table calls for a report of movement of insane pati-
ents apart from other patients, who may be eared for in the
same institution. As rates of admission, discharge and death
'will be computed from the data, submitted from" this table,
it is important that the directions included therein, be very
carefully followed. For convenience of reference, the prin-
cipal terms used in this table are herein defined. These terms
have the same significance wherever used in the tables de-
scribed in this manual.'

" First admissions " includes all insane patients admitted
for the first time to any institution for the insane, public or
private, wherever situated, in or outside of state, excepting
institutions for temporary care only.

" Readmissions " includes all insane patients admitted
who have been previously under treatment in an institution
for the insane, excepting transfers and patients who have re-
ceived treatment only in institutions for temporary care.

" Recovered " indicates the condition of patients who have
regained their normal mental health so that they may be con-
sidered as having practically the same mental status as they
had previous to the onset of the psychosis.

" Improved " denotes any degree of mental gain less than
recovery,

A " voluntary patient " is one who is received in an institu-
tion upon his own application and without commitment

Table 4. Nativity op First Admissions and of Parents of
Fikst Admissions
Care should be taken to ascertain the country of birth of
every first admission. Changes in national boundaries made
by the present war should not be recognized until its close
and until the new boundary lines, if any, are definitely fixed.

JigitizecOydOOQlC

The following is the list of countries to be used in reporting
nativity :

Modified Form of United States Census Classification of Nativity

Africa

Fiance

Porto Rico

Aeiat

Qermany

Portugal

Australia

Greece

Koumania.

Austria

Hawaii

Russia

Belgium

Holland

Scotland

Bohemia

Hungary

South America

Can a da J

India

Spain

Central America

Ireland

Sweden

China

Italy

Switzerland

Cub*

Japan

Turkey in Asia

Denmark

Mexico

Turkey in Europe

England

Norway

Wales

Europe!

Philippine Islands West Indies"

Finland

Poland

Other countries

+ Not otherwise specified.
t Includes Newfoundland.
•Except Cuba and Porto Rico.

Table 5. Citizenship of First Admissions

Accurate data concerning the citizenship of first admis-
sions in the several states is highly important as the matter
has a direct bearing on the policy of the United States rela-
tive to immigration.

The following notes pertaining to citizenship may be found
helpful :

Foreign-born persons (with few exceptions) are aliens un-
less naturalized and should be so reported if evidence of their
naturalization ean not be produced.

Aliens may be naturalized in several ways, as follows :

1. By making required declarations and receiving final
naturalization papers from a court of competent jurisdiction.

2. A woman, by the naturalization of her husband or by
marriage to a citizen.

3. Minors, by the naturalization of their parents.

All persons (with few exceptions) born in the United
States are citizens regardless of parentage.

A woman loses her citizenship by marriage to an alien.

A declaration of intention does not confer rights of citi-
zenship; a foreigner is an alien until naturalized. An alien,
to be eligible for citizenship, must have resided in the United
States continuously for five years.

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Table 6. Psychoses of Fibst Admissions
In diagnosing the mental diseases of patients, the instruc-
tions given in this manual (pages 14-29) should be carefully
studied and followed so far as possible. In making out the
table, give the total for each numbered group and so far as
may be determined the number in each subdivision thereof.

Table 7. Race of First Admissions Classified with Ref-
erence to Principal Psychoses
The race of patients admitted should be designated by the
terms given in the following list :

African (Hack)

Greek

Scotch

American Indian

Hebrew

Slavonic"

Armenian

Irish

Spanish

Bulgarian

Italian*

Spanish-American

Chinese

Japanese

Syrian

Cuban

'Lithuanian

Turkish

Dutch and Flemish

Magyar

Welsh

East Indian

Mexican

West Indian (except

English

Pacific Islander

Cuban)

Finnish

Portuguese

Other specific races

French

Roumanian

Mixed

German

Scandinavian!

Race unascertained

+ Includes " north " and " south."
t Norwegians, Danes and Swedes.

■Includes Bohemian, Bosnian, Croatian, Delmatian, Herzegovinian, Mont-
enegrin, Moravian, Polish, Russian, Ruthenian, Servian, Slovak, Slovenian.

The " Dictionary of Races " prepared by the Immigration
Commission should be used as a guide for the determination
of race. A pamphlet copy of this excellent manual may be
obtained from the Superintendent of Documents, Washing-
ton, D. C, for twenty cents.

The following suggestions relative to race classification
should be carefully noted :

African. This term should be applied to all negroes of
pure or mixed blood, whether coming from Africa, Cuba or
other West Indian Islands, Europe or North or South
America.

Jigitizccty GoOglc

Armenian. Care should be taken not to confuse Armen-
ians with Syrians.

Bulgarian. The Bulgarians who come to the United
States are all from Bulgaria but, with the readjustment of
boundary lines which may follow the present war, it is likely
that in the future it will not always be possible to distinguish
Bulgarians by their starting place in Europe. The language
should identify them in all cases.

Cuban. Care must be taken not to include negroes and
Spanish-Americans among " Cubans."

Dutch and Flemish. Nearly all the Dutch who come to
the United States come from Holland. They call themselves
" Hollanders." The Flemish come principally from Belgium.

East Indian. This term refers to the natives of the East
Indies, including Hindus, and is a very loose term, ethnologi-
cally. This is a matter of small importance, however, as
very few immigrants come to the United States from the
East Indies.

English. Care must be taken to exclude Hebrews who
are born in England, also English-speaking people of other
races.

Finnish. All natives of Finland are not Finns; many of
them are Swedes. Of the Finns living in Europe, more than
1,000,000 live outside of Finland.

German. Care must be taken to classify Germans from
Russia as Germans.

Hebrew. No difficulty will be experienced in identifying
Hebrews and they should be so classified without regard to
the country from which they come.

Italian. Very few Italians come to the United States from
any country except Italy, although some come from Brazil
and the Argentine Republic. Care must be taken not to con-
fuse these with Spanish-Americans.

Lithuanian. Lithuanians in the United States are quite
likely to be confused with Poles or Slovaka They are quite
distinct from the " Slavonic " people and should be enumer-
ated separately.

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Magyar. Magyars are often called "Hungarians,"
*' Huns " or " Hunyaks " in popular language in this country.

Ro u man i an. In reporting patients born in Roumania,
the only chance for error is the failure to exclude Hebrews
and Gypsies. There are about half as many Roumanians in
Hungary as there are in Roumania and so it is necessary to
consider them in reporting the race of natives of Hungary.

Slavonic. This is a very important racial division as a
very large number of Slavonic immigrants have come to the
United States in recent years. It is believed that the use of
this term will solve a great many difficulties as it makes it
unnecessary to distinguish between Poles, Slovaks, etc. The
only danger to guard against is that of including Lithuanians,
Finns, Magyars or Roumanians.

Spanish. Care should be taken not to apply this term to
Spanish-Americans.

Spanish- Americans. This term refers only to " the peo-
ple of Central and South America of Spanish descent"

Turkish. Armenians and Syrians should not be included
under this designation.

West Indian. Care should be taken to exclude negroes,
Cubans and Spanish-Americans. Only a very small number
of West Indians not negroes, are admitted to the United
States.

Mixed. This term should be used to designate the race
of a patient whose ancestors were of two or more races.

The terms "American," " Swiss," and "Austrian," should
not be used to designate race (see discussion of these terms
in the "Dictionary of Races:" American, p. 102; Swiss, p.
138 ; Austrian, p. 20).

Table 8. Age of First Admissions Classified with Refer-
ence to Principal Psychoses

In filling out this table and the other tables in which the
principal psychoses are correlated with other items, care
should be taken to give the same totals for each group in
every table.

Age groups as designated in the headings are inclusive,
e. g., 15-19 years includes the years 15, 10, 17, 18 and 19.

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Table 9. Degree of Education of First Admissions Clas-
sified with Reference to Principal Psychoses

" Illiterate " denotes persons who cannot read and write.

Under " reads and writes " should be included those who
have attended a common school but who have not completed
the work of the fourth grade. Common school, high school,
and college should be interpreted as meaning graduation from
such institutions respectively or completion of at least half
of the prescribed course. Two years of a course taken in a
professional school, snch as medicine, dentistry and phar-
macy, should be considered as college education. Business
schools are principally of common school grade although a
few are of high school or college grade.

Table 10. Environment of First Admissions Classified
with Reference to Principal Psychoses
" Urban " and " rural " are used in this table as in the
United States census classification. Places having a popula-
tion of 2,500 or more are considered as " urban." All other
places are considered as " rural."

Table 11. Economic Condition of First Admissions Clas-
sified with Reference to Principal Psychoses
The term " economic condition " refers to the patients' cir-
cumstances before the onset of the psychosis. The terms used
in classifying " economic condition " are defined as follows:

Dependent: Lacking in necessities of life or receiving aid
from public funds or persons outside the immediate family.

Marginal: Living on daily earnings but accumulating
little or nothing; being on the margin between self-support
and dependency.

Comfortable: Having accumulated resources sufficient
to maintain self and family for at least four months.

Patients should not be classed as " dependent " because
they are not able to reimburse the hospital for their mainten-
ance provided they were previously able to maintain them-
selves. Minors and aged people cared for by their families

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